Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Monday, June 18, 2007

(Editors note: For those of you new to this blog ETOTHEIPI, the contributor writing here, is a board certified pathologist who has performed many autopsies. The autopsy report from the current case in L.A. which is generating so much press can befound here)

Here are some notes on the autopsy report from the previous post "Emergency Bleeding". Review before continuing or this will make little sense.

1. Ignore the scratches on the last few pages of the report - it is unreadable - those are just notes at the time of autopsy and are all incorporated into the typed text. The only thing additional I picked up was the presence of multiple tattoos - which personally shocked me.

2. Take note of how they removed the tongue. My favorite part of the autopsy. You open the chest, reach your hand up through the neck and by cutting along the inner aspect of the jaw, you loosen the tongue and then rip it out through the neck and chest. Just good clean fun.

3. Note the NORMAL aorta. I think it is a reasonable guess that this 5'6", 274 lbs., tattooed beauty, has elevated cholesterol and eats like a starving rhino let loose in KFC. Why is her aorta normal? It's probably alcohol. It is a well known phenomenon that alcoholics have great vessels - sure your liver fails - but you can't get something for nothing.

4. Bottom line: the report states that the inflammatory reaction to her colon perforation was consistent with an acute process. She probably had a dilated colon from drugs and pre-existing divertics from being 'eating-challenged' - hence abdominal pain. One of her divertics got blocked by poo - possibly a 'Corn-Nut'. It got inflamed and burst. End of story and life.

5. Shit luck for the docs / triage folks who missed this - would like to hear comments from said persons on picking up an acute abdomen in a such an 'adipose-gifted' individual.

6. Lastly, it doesn't strike me that this alcoholic, obese, meth-addict had much concern for her own personal health. She died and it was her own fault. Now the hospital and docs will be out a few million. Sure insurance will pay, but guess where that money to pay comes from... yep, the docs who pay ridiculous premiums (>100,000$/year pre-tax!!! for some). Hmmmm... I pay lots of money so someone who has no respect for herself can get rich... Oh wait, she's dead. We all lose.

You're giving corn nuts a bad name. I'll have you know I lived on corn nuts, beef jerkey and yoohoos for a year. I heard from a reliable source (I'll call him "Deep Throat") that it was a chicle stuck to a laffy taffy that clogged her tic.

Here's a woman with a pitiful life, who dies a miserable and painful death on a floor among strangers. Isn't that bad enough without your publicly heaping scorn on her, mocking her tattoos and comparing her to a rhino?

here's something pitiful. my current patient, who, through NO FAULT OF HIS OWN, is a quadruple amputee and will die on the operating table tonight.

the woman who died in the post above made choices. she made bad ones. it caught up with her and everyone loses.

go peddle your ill-informed idiocy somewhere else and thank God that there are still people who, regardless of whether they ever get paid for caring for these patients or not, still give them the best care available on the planet.

yes, she died. yes, her diagnosis was missed, yes, she had been evaluated for the same complaints many times, yes, she was obese which makes the diagnosis much harder, yes, she was an alcoholic and meth abuser, yes, the hospital and the doctors involved will lose the lawsuit, and yes, it was mostly her fault.

ETOTHEIPI, to answer your original question. first, since she was in the ED a lot and most of the staff knew who she was (either by visual recognition or by chart review) the temptation was to blow her off.

she probably had normal vitals and had something similar to her usual complaint.

she probably waited forever OR had just been discharged.

at some point an ED doc wondered whether he should do a CT scan AGAIN on her and probably settled for labs, plain films, and, i shudder, a pelvic exam.

when these were normal and she passed a PO challenge she was discharged.

it is likely that she was taking some form of tylenol or motrin or aspirin and was therefore, if not afebrile, nearly afebrile.

the short answer is that she needed a CT scan or an ED doc or surgeon on call to put aside her history and start, AGAIN, from square one.

Maybe this person, who I freely admit I have never met, was a wonderful, loving individual whose tragic death has made the world a worse place. I am simply basing my comments on a pathology report which tells me nothing of her personality. All I know is she was definitely a tattooed drug-addict who was morbidly obese. The factors that led to her death were clearly her own fault. And BTW, get a sense of humor - I mock because I care.

Didn’t you realize most of the people you served would be the great unwashed? Unwise choices, that sounds like something on Oprah. How about, there for the grace of God go I, or someone I know and love.

Maybe you had 50 more IQ points then this lady, maybe you were saner, maybe you came from a nice family that gave you a good start in life (and wouldn't let you die on the ER floor as the janitor cleaned up after you); who knows why some people make it and some don’t.

Wow- one of the few medical blogs that even mentioned this case and this is what the general trend is. What an eye opener.

If I shit in your water supply as your children drink out of it, do I deserve to be respected? This person should disgust you. Pointing out that this person is a bad person is appropriate. This is a general comment and not necessarily related to the dead-waiting-room-floor person.

How can "a few medical blogs" mention this case and at the same time be a "general trend". Huh?

If anyone says: "and there for the grace of god go I" again I am going to poke my own eyes out, old school, Oedipus style.

Here's a real eye-opener: I believe people should take responsibility for themselves. Wow, what a concept. And by the way, I am the son of a Thai prostitute and a sailor, brought up in a brothel by crack addicts. I know why some people make it and others don't, bitch. Out.

Why do people keep harping on the janitor mopping up this woman's puke? He was doing his job. His job isn't to triage patients, to make medical judgments, or to oversee patient flow in the ER. His job is to mop the floor, and apparently he did his job in an exemplary fashion.

At least he has a job, unlike some meth-addicted homeless parole violators I can think of.

Not every smart, successful, professional is the result of a good family and up bringing. The woamn who died could have been brough up in that of the upper class. Judgements are being made that shouldn't.

The fact is she made choices to be a drain on society. That doesn't imply she deserved to be mistreated, but the responsibilty as to her lifestyle lies with her.

If I were to go the way of my up bringing, I would be a HS drop out serving up fries as opposed to an accomplished business person/attorney. She made choices and though now dead, has to be held accountable.

Why is it that the general public always feels sorry or makes excuses for the people who make poor choices in life.

Simple fact she was an addict and an ED frequent flier who managed to get the drugs she was seeking. Unfortunately for the medical professionals involved she bit the big meth ball in the sky.

I've learned my lesson the frequent visitors to the ED will all be the most emergent cases to be seen before all chest pain or other life threatening issues.

When Anonymous arrives at triage for the 50th time to complain they have been waiting 3.5 hours with chest pain, I'll calmly and with a smile on my face explain that the Corn Nut eating Rhino is a high priority case!

I'm sorry to inform you that you are the reason this woman died. Sadly, you are also the reason for the rising cost of medical care. Ironically, you are even the reason medical professionals have to start Blogs like this to be able to vent here instead of at work.You see, you are a propagator of the belief that we are all ENTITLED to do whatever we please, and still receive the same unbiased perspectives as those that do what they should. It saddens me to know that you value the rights of a women who died by her own hand MORE than you value the rights of the people who are left to deal with the mess she left. I believe her family should have been made to mop the floor. We live in a free nation, but with that freedom comes responsibility. She chose not to be responsible. Perhaps somewhere during her multitude of ER visits, she caused the death of someone who didn't get the care they needed due to stretched resources. If you live your life with courage (anonymous), you don't burden others with troubles of your own making. I imagine Hitler was the product of a troubled childhood, but at some point that just isn't enough to make most people's hearts melt for him. This woman simply relied on a society she contributed nothing to...and burdened often. How much compassion is too much?

Ok, after one hell of a long suck ass shift of nothing but a bunch a freaks(!-LITERALLY--I can usually find at least one person that I have taken care of in a 12 hour shift that will remind me why I became a nurse, and actually sustain me through either the rest of that shift or the upcoming shift...not so last night!) So, when I come home and read this thread...I have to comment...

To anonymous...I can tell you why some people make it and some people don't...it has everything to do with Darwin! If liberals hadn't intervened, Darwin's theory would be 100% supported and stupid fuckups would eventually stop reproducing. But since liberals stepped in and started treated that vast majority of dumbass deadbeats as an endangered species, they are thriving! They are "making it" as you say. The "deserving" ones coming down with cancer, type 1 (NOT TYPE 2!!!!!) diabetes and other things people are "just born with" don't "make it." I wouldn't be surprised if you were one of the freaks I took care of last night! I and do mean "take care of"--because most of us touch and treat our patients with respect and dignity--unlike how we are treated much of the time.

No, this person didn't "deserve" to die...do her offspring "deserve" to be millionaires?

So, c., what kind of attorney are you? You wouldn't jump at this one?

Off to la la land so that I might save another undeserving soul tonight...

Thanks realistic RN. I hope the freak factor is lower tonight at work.911doc, thanks once again for the music. I've been listening to it none stop! It really helps make the clock tick faster. Hope you're having an incredible summer.

tommy,actually, still TONS of freaks. I thought the cycle was broken, and said so out loud, only to be very disappointed. Yep, another freak. However, I did have one patient that made me remember "why" and am honored that I got to "take care of" him (and his uncle.) See? There really is usually one per shift (on a really good night there may even be 2 or 3--VERY RARE!)

RealisticRN,It was the saying it out loud that got you. It's the common, self-inflicted jinx. I'm glad providence threw you a bone and gave you a good one to justify showing up for work. I imagine it is the good ones that keep all of you doing what you do.